Case of the Day

A 72-year old woman presents with a complaint of headache and that
her right eye "just isn't working right." She is generally healthy, with
only an idiopathic anemia, and no associated symptoms other than some
fatigue and poor appetite. She characterizes the headache as being a
sinus headache, and notes that it has been occurring on and off for a
month or so, though she has never had any fever or nasal
congestion/drainage. She has had "eye problems" related to this headache
in the past, but today it is more severe than before.

When the patient looks at you, this is what you see:

She cannot voluntarily retract the right eyelid. It is nontender, and
when you retract it for her, she complains of diplopia. You see this:

The right pupil is dilated and fixed; the left is 3 mm and reactive.
Note that with level gaze the eyes do not seem quite conjugate. The
right eye is deviated mildly down and out. When you ask the patient to
look to her left:

There is no movement of the right eye at all. And when you ask her to look up:

Again the right eye does not move. Same with downwards gaze. On attempted right gaze you see this:

But on right gaze the patient still complains of diplopia. Vision in the
right eye is grossly intact to confrontation. The right pupil reacts
neither to light or attempted accommodation (on a very limited exam).
Neurological exam is otherwise entirely normal, including as many
cranial nerves as an ER doctor remembers how to test.

So -- what is the clinical finding here, and where is the lesion most likely to be based on the information you have?

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